Knowledge of FAS and the Risks of Heavy Drinking During Pregnancy, 1985 and 1990

Reducing the incidence of FAS to no more than 0.12 per 1,000 live births is a stated objective of the national agenda in Healthy People 2000. One step toward attaining this is by ensuring that all prospective mothers know what FAS is. Knowledge of FAS was elicited among respondents in two health surveys to determine how much women and men know about the risks of drinking during pregnancy, how knowledge levels have changed over time, and what the implications of these findings are with regard to reducing the level of FAS among newborns.

T his Epidemiologic Bulletin ex amines changes in respondents' attitudes toward the risks of heavy drinking during pregnan cy, their awareness of fetal alcohol syn drome (FAS), and their knowledge of what FAS is. Although the respondents are women and men ages 18 to 44 years, the detailed analyses presented here focus on women only. Data were extracted from the Health Promotion and Disease Pre vention (HPDP) supplements of both the 1985 and the 1990 National Health Inter view Survey (NHIS).

BACKGROUND
One of the important contributions of biomedical research in the past century is the demonstration that personal lifestyle choices make a significant difference in the measure of health and quality of life. Accordingly, a national agenda aimed at considerably reducing preventable death and disability and enhancing quality of life by the year 2000 has been initiated. Healthy People 2000 (U.S. Department of Health and Human Services 1991) is a substantial effort involving health profes sionals and citizens, public agencies, and private organizations from all over the United States. Work on the objectives began in 1987 with the creation of a consortium that now includes nearly 300 national membership organizations as well as all State health departments.
More than 300 specific objectives in 22 priority areas were identified in Healthy People 2000 as goals targeted for achieve ment by the year 2000. One of these objec tives is to reduce the incidence of FAS to no more than 0.12 per 1,000 live births. A step toward attaining this level would be to ensure that all prospective mothers know what FAS is. Although increased knowl edge and awareness do not necessarily lead to changes in behavior, it is unlikely that changes such as decreasing or eliminating alcohol consumption during pregnancy will occur in the absence of knowledge of the risks of not doing so. Therefore, three important questions have to be addressed: How much do women in the United States today know about the risks to the fetus that are associated with alcohol consumption during pregnancy, particularly FAS? How have knowledge levels of FAS changed over time? What are the implications of such findings with regard to achieving the Healthy People 2000 goal for FAS?
The purpose of this study is threefold. First, it will examine changes since 1985 in the percentage of men and women ages 18 to 44 years who believe that heavy drinking during pregnancy increases the chances of miscarriage, mental retardation,  In thousands. Abstainer : fewer than 12 drinks in any 1 year. Former drinker : 12 drinks or more a year previously, but no drinks in the past year. Current drinker : 12 or more drinks a year previously and at least 1 drink in the past year. Risk drinker : average of more than one drink a day (women); average of more than two drinks a day (men).

2
Subgroup of current drinkers.
low birth weight, and birth defects; who have heard of FAS; and who can correctly describe FAS. Second, it will examine whether differences in these areas of belief, awareness, and knowledge exist among all women, current drinkers, and risk drinkers. Third, it will examine whether differences exist among demographic subgroups in the population of women of childbearing age.

Sources of Data
Data for this study were derived from HPDP supplements in the 1985 and the 1990 NHIS. These questionnaires were first developed to monitor progress on national health objectives for the year 1990 and, later, for the year 2000. In the section involving risks of heavy drinking during pregnancy, awareness of FAS, and knowl edge of FAS, survey respondents between the ages of 18 and 44 years were asked a series of questions about their agreement as to whether heavy drinking during pregnan cy increases the chances of miscarriage, mental retardation, low birth weight, and birth defects. Heavy drinking was re spondent defined; that is, each respond ent used his or her own criteria of heavy drinking. Thus, different respondents may have interpreted the questions in many different ways.
Respondents were asked to indicate whether heavy drinking during pregnancy "definitely increases," "probably increas es," "probably does not increase," or "defi nitely does not increase" the chances of these complications. A response of "don't know" also was valid. The responses "def initely increases" or "probably increases" were collapsed to represent agreement.
These same respondents were then asked if they had ever heard of FAS. Those who replied affirmatively were asked to select a response that best described FAS. The choices were a baby that is "born drunk," "addicted to alcohol," or "born with certain birth defects." ("Born with certain defects" is the correct response.)

Respondent Categories
Respondents were grouped into several categories, with "all" representing the total U.S. noninstitutionalized population ages 18 to 44 years. "Abstainers" were defined as persons who have had fewer than 12 drinks in any 1 year. "Former drinkers" were defined as persons who have had at least 12 drinks in 1 or more years previously but no drinks in the past year. "Current drinkers" were defined as persons who have had at least 12 drinks per year previously and at least 1 drink in the past year. "Risk drinkers" were de fined as persons who drank at levels higher than the levels of moderate drink ing suggested in the Dietary Guidelines for Americans (USDA/ USDHHS 1990). For women, risk drinking was defined as average alcohol consumption of more than one drink per day. For men, risk drinking was defined as average alcohol consumption of more than two drinks per day.

Analyses and Tests of Differences
Tests of differences in proportions between response categories in the 1985 and the 1990 HPDP supplements were made by comparing 95 percent confidence intervals; 1 differences were considered significant when the 95percent confidence intervals did not overlap. Standard errors used to construct the confidence intervals were based on estimates from SESUDAAN, a computer program that estimates standard errors and takes into account complex sampling designs such as those of the NHIS (Shah 1981). NHIS responses were weight ed to be representative of the 1985 and the 1990 U.S. population.
The items selected for analysis from the HPDP supplements fall into dimen sions of beliefs, awareness, and knowl edge. Responses to items related to risks of heavy drinking during pregnancy essentially represent beliefs or attitudes about heavy drinking. Responses to items related to the respondents having heard of 1 A confidence interval is a range of values that carries a specified probability of including a parame ter, such as a percentage estimate. With a 95percent confidence interval, one is confident that-95 times out of 100-the "true" value will be within the range of values. When the 95percent confidence intervals of two like measures do not overlap, the measures are considered to be significantly (p < 0.05) different. Average of more than one drink a day (women); average of more than two drinks a day (men). FAS represent awareness, perhaps in large part influenced by public education and the media. Responses to items related to the respondents' ability to distinguish among three response alternatives and correctly identify FAS as a child born with certain birth defects represent some level of knowledge of FAS.  a child born with certain birth defects, 39 heavier drinking during pregnancy, had population in the awareness of FAS also percent correctly described FAS in 1990.

Sample and Overall Findings
heard of FAS, and could correctly de were found among most drinking cate Many of the beliefs, awareness, and scribe the syndrome.

gories. Abstainers were significantly less knowledge increases between 1985 and
For both genders, a larger percentage likely than the total population to have 1990 were shared among men between of current drinkers compared with the heard of FAS; former drinkers, current the ages of 18 and 44 years, yet a signifi general population were aware of the drinkers, and risk drinkers were signifi cantly lower percentage of men than stated risks of heavy drinking and of FAS. cantly more likely than abstainers and women believed in the stated risks of Significant differences from the general the general population to have heard of FAS. In being able to describe FAS, however, none of the percentage correct responses among the drinking groups were significantly different from the general population or from the other drinking groups.  are characteristic of various demographic subgroups of women in this age group.

Detailed Differences by Demographic Characteristics
For all women and current drinking wom en, changes between 1985 and 1990 were fairly consistent and significant across most of the demographic subgroups. The exceptions were the black, Hispanic, less than 12 years of education, less than $20,000 family income, unemployed or not in the labor force, and the divorced/ separated categories, where increases were not significant. Significant increases also were found among current drinking women compared with the general population of women, because current drinkers were more in clined to agree on the risks of heavier drinking during pregnancy in the first place. However, among women risk drinkers, significant differences across 1985 and 1990 were found only among women 30 to 44 years of age, women with family incomes of $50,000 and over, and women residing in the South. Compared with all women combined, Hispanic wom en in 1985 and 1990 were less likely to agree that heavy drinking increases the chances of birth defects, as were women with less than 12 years of education. Table 4 presents the percentage of women in selected demographic sub groups in 1985 and 1990 who reported that they had heard of FAS. A significant increase in the awareness of FAS between 1985 and 1990 was evident among all of the subgroups examined for both all women and current drinking women of childbearing age. However, among sub groups of risk drinkers, significant in creases in awareness were found only among groups 30 to 44 years, white, nonHispanic, employed or other status, married, and living in the Northeast.
Black women, Hispanic women, and women with family incomes of less than $20,000 per year were less likely than all women combined to have heard of FAS. On the other hand, women ages 30 to 44 years, living in the Midwest, and with more than 12 years of education were more likely to have heard of FAS than were all women combined. Table 5 presents the percentage of all women, current drinkers, and risk drink ers who correctly chose the response that best described FAS, that is, a child born with certain birth defects. Significant increases between 1985 and 1990 in this knowledge generally were found within each of the demographic subgroups exam ined, except for risk drinkers.
The lack of many significant increases among risk drinkers in their knowledge of FAS between 1985 and 1990 could be attributed to low sample sizes in the sub groups. For risk drinkers, a larger percentage change would be necessary than for the other analytic groups to indicate statistical significance. However, some increases in the correct responses about what FAS is were found among women risk drinkers of childbearing age who were older (ages 30 to 44 years), had family incomes of $20,000 to $34,999, and were divorced or separated.

DISCUSSION
Increases since 1985 among women ages 18 to 44 years regarding their agreement on the risks of heavy drinking, their awareness of FAS, and their ability to correctly describe FAS are encouraging. The level of knowl edge among these women regarding what FAS is, however, is still disturbing. Thirty nine percent of women of childbearing age who had heard of FAS could correctly de scribe it in 1990. This means that only 29 percent of all women of childbearing age (whether they had heard of FAS or not) could correctly describe it. The figure for all women of childbearing age in 1985 was only 16 percent. Obviously, more prevention and education efforts are needed to inform women of the dangers of heavy drinking and of any drinking during pregnancy.
The changes between 1985 and 1990 in awareness and knowledge of the dan gers of alcohol use and birth defects can not be attributed to alcoholic beverage warning labels to any great extent, be cause warning labels were not present on most alcoholic products for sale until 1990 (Hankin et al. 1993) (see the article by Hankin,. Data in these surveys show that most women of child bearing age agree that heavy drinking increases the risk of mental retardation and birth defects. However, less than a third can correctly describe FAS. While this may be a contradiction, it seems advis able for prevention to focus on knowledge as opposed to attitudes, where FAS sever ity may be underestimated. Also, it is problematic whether there is any real relevance to being aware of FAS if most of these women of childbearing age can not correctly identify what FAS is. Perhaps prevention efforts should focus on the specific birth defects characteristic of FAS.
The number of women and men who believe that FAS is a child born addicted to alcohol may be related to the public atten tion given to crack babies. Whether such women and men simply believe that a newborn child can "dry out" or recover with abstinence, and thus sustain no lasting harmful effects, is unknown.
Evidence of increased risk of FAS at low levels of alcohol consumption has not been firmly established, but even moderate levels of alcohol intake during pregnancy have been associated with developmental and other problems (Walpole et al. 1990;Waterson and MurrayLyon 1990; also see the articles by Day and Richardson,and Jacobson and Jacobson,. Since 1983, the American Medical Association has recommended that physi cians advise women against any drinking during pregnancy because of the potential dangers of alcohol consumption to the fetus (Waterson and MurrayLyon 1990).
Those groups who are less likely to believe in the risks of heavier drinking, to be aware of FAS, or to correctly define it may need special targeting for general prevention efforts and specific intervention efforts with women who are pregnant. Results from this study and other studies (Serdula et al. 1991) suggest that such groups often are drinkers who are young (under age 30), black, Hispanic, or with limited years of education-groups already at risk for poor pregnancy outcomes, prob lems often compounded by socioeconomic status. Weiner and colleagues (1989) sug gest that primary prevention efforts and direct interventions that focus on changing drinking behavior have an excellent chance of succeeding, especially when delivered by physicians or other health care providers. ■